Reading of the Week: First Episode Psychosis and Access – The Anderson-Kurdyak Paper, and More

From the Editor

“If your son or daughter had cancer or diabetes, do you think it would be reasonable for them to wait? I don’t think it’s any different for mental illness.”

Access. It’s one of the biggest problems with mental health services.

How big is the access problem? What can be done about it?

This week, we consider a new paper looking at access and first episode psychosis. Dr. Paul Kurdyak, a CAMH psychiatrist and a program lead with the Institute for Clinical Evaluative Sciences, made the above comment to the CBC when discussing this new paper. In it, Kelly Anderson and Dr. Kurdyak find that 40% of patients didn’t receive physician follow-up in the month after diagnosis. Imagine – tying back to Dr. Kurdyak’s comment – if 40% of young patients with leukemia didn’t have physician follow-up in a month after their cancer diagnosis.

We also look at the discussion around a new federal-provincial accord with an op ed written by Michael Wilson, the chair of the Mental Health Commission of Canada – particularly timely as the ministers of health met this week with an eye on a new accord.

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Reading of the Week: Starbucks’ Big Mental Health Announcement, and More

From the Editor

Readings in recent weeks have drawn from several journals and a major autobiography.

Recognizing that mental health is increasingly part of our public and private conversations, we draw from newspapers and news sites this week.

image001Starbucks: fraps, breakfast sandwiches, and psychotherapy (for employees)

The decision of Starbucks to expand employee coverage for psychotherapy leads this week’s lineup.

We also consider the first Parliamentary speech of an Australian politician and a new British exhibit of old art – from asylums.

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Reading of the Week: What’s New in Psychotherapy – Paul Garfinkel’s Book

From the Editor

What’s new in psychotherapy?

Psychotherapy is an area of psychiatry transformed over the past years.

Dr. Aaron Beck: not a Freudian

Last week, we looked at a major new paper on IPT. This week, we return to Dr. Paul Garfinkel’s book – the source of two past Readings – for an excellent chapter on psychotherapy.

Last week. A major new review of IPT.

This week. An overview of psychotherapy developments.

This chapter describes the evolution of psychotherapy, and its importance. It also notes the excellent opportunity for the mental health field – to embrace evidence-based treatments and to offer better care for our patients.

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Reading of the Week: What’s New in Psychotherapy – The Cuijpers et al. Paper

From the Editor

What’s new in psychotherapy?

If there is one area of psychiatry that seems to have been transformed in recent years, it’s psychotherapy. Not surprisingly, then, past Readings have looked at the expanded role of short-term, evidenced-based therapies – in particular, Cognitive Behavioural Therapy, or CBT.

Today’s psychotherapy: a long way from Freud

Over the next two weeks, we’ll look in more detail at new developments in psychotherapy.

This week. A major new review of IPT.

Next week. An overview of psychotherapy developments.

This week, we consider a new paper published in The American Journal of Psychiatry on Interpersonal Therapy, or IPT. This paper is clear, lucid, and worth reading.

Is there evidence for IPT? Yes – and more than just for depression.

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Reading of the Week: Kurdyak’s New Paper on Access

From the Editor

As medical school classes have grown, the supply of physicians has increased across the country. Has this helped address access issues in psychiatry?

How have practice patterns changed over time?

This week’s Reading seeks to answer some basic and important questions around physician supply and access in psychiatry. Following up on a major paper written in 2014, Kurdyak et al. have written another important and relevant paper.

The long and the short of it: there are significant problems with access – and they aren’t getting any better with time.

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Reading of the Week: Guest Contribution – Dr. David Goldbloom on Locked Doors and Hospitalizations

From a Contributing Editor, Colleague and Friend of the Editor

This week’s reading is a provocative companion piece to the recent review of efforts to reduce involuntary admission to hospital. It is the environmental expression of the legal deprivation of freedom of movement: the locked door. Locked doors have a powerful symbolic meaning in psychiatry; outpatients coming for elective consultations sometimes tell me they are afraid if they “say the wrong thing” that I will “lock them up”. Asylum superintendents carried large rings of keys that embodied power and control.

Locked doors, better outcomes?

Having spent half my career working on inpatient units, I am, like almost all of you, familiar with the locked doors that distinguish our wards from all others found in a hospital. And I know the reasons for their justification: prevention of elopement by people at risk of harm to themselves and others. And that prevention is intended to serve not only the patient and family but also the clinicians and the institution in terms of risk management. And yet…people do elope. Sometimes they return and sometimes they do not. Sometimes they attempt or complete suicide and sometimes they do not.

There is, as always, a tension between safety and risk, between freedom and protection, between autonomy and control. Locks are ubiquitous but not universal on psychiatric wards. What do we know about whether they make a difference? And what would be the ethically acceptable methodology for determining it?

– David Goldbloom, OC, MD, FRCP(C) Continue reading

Reading of the Week: Guest Contribution – Dr. David Goldbloom on Involuntary Hospitalizations

From a Contributing Editor, Colleague and Friend of the Editor

All of us psychiatrists have exercised our responsibility for the involuntary admission of patients. Some patients (and many families) have expressed gratitude for this temporary but fundamental abrogation of civil freedoms – the freedom of movement – but for many patients it may be a source of fear and of loss of control and autonomy (even though the illnesses that they are experiencing also undermine control and autonomy). It may also reflect an upstream failure of less intrusive and earlier interventions to treat mental illness.

Involuntary admission: is there an alternative?

In an era of being patient-centred and recovery-focused, is a reduction in rates of involuntary hospitalization desirable? If you’re a human rights lawyer, the answer may be “well, yes, obviously”. If you’re a clinician, the answer may be “that depends on whether the patient ends up better or worse”. Nevertheless, there are a number of clinical initiatives in place whose goal would be to reduce the frequency of involuntary hospitalization (which does not preclude an increase in the rate of voluntary hospitalization).

So along comes a careful systematic review and meta-analysis of randomized trials to examine four categories of intervention that have, as their explicit primary or secondary outcome, a reduction in the rates of involuntary admission to psychiatric inpatient units. The interventions will seem familiar to any reader who has been involved in the care of people with severe and persistent mental illness. But the results are surprising.

– David Goldbloom, OC, MD, FRCP(C) Continue reading

Reading of the Week: Doing Things Differently – Clozapine and More

From the Editor

“When a Cape Breton cousin of mine was hospitalized at the main asylum for Nova Scotia in the 1940s with psychotic symptoms, his sister told me the family received a phone call from the treating physician telling them to give up all hope for their brother’s future.”

In his new book written with Dr. Pier Bryden, Dr. David Goldbloom – past Chair of the Mental Health Commission of Canada and Senior Medical Advisor of the Centre for Addiction and Mental Health – recalls the story.

Psychiatry is so much better today.

But there is room for much improvement. Uneven outcomes. Provider-focused care. Can we do things differently?

New approach, better results?

This week, we look at a blog published by, considering the use of clozapine for people with schizophrenia. Dr. Adam Rose, drawing on the research, including his own research, wonders why we don’t use more of this effective treatment.

Then, turning to The Globe and Mail, we look at the life and death of Dr. Kate Granger – a physician who has challenged us health care providers to be more compassionate.

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Reading of the Week: Hospitalizations and Ethnicity (and Stigma)

From the Editor

Younger and sicker.

This week, we look at a new paper published in The Journal of Clinical Psychiatry considering ethnicity and hospitalizations. Drawing on Ontario data, researchers looked at psychiatric hospitalizations for people of Chinese and South Asian descent, finding that they were younger and more ill at the time of admission.

Hospitalizations, ethnicity… and access

Lead author Maria Chiu of the Institute for Clinical Evaluative Sciences told the Toronto Star:

Cultural factors play a big role in these findings. While Asian people tend to have stronger family support, they are also faced with a higher level of stigma and it prevents people from seeking help early. Families may try to cope and keep the illness within the family until there is no choice but to go to hospital.

This paper is well designed. It’s also important, speaking to larger issues about access, stigma, and ethnicity.

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Reading of the Week: Olympics and Mental Illness

From the Editor

This is the Olympics edition of the Reading of the Week.

We will remember Rio for much – the big smile on Penny Oleksiak face when she won gold; the grit of the Canadian women’s soccer team; the achievements of American Michael Phelps.

For me, there is also the amazing story of swimmer Allison Schmitt. I’ll remember her not just as an Olympian who competed. That’s memorable of course. But she is also memorable for being an athlete willing to talk about her struggles with mental illness.

For the record, Schmitt won gold and silver in the pool in Rio.

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